NC Participation Form

2026 Annual Participation Form

This Participation Form certifies that the local government intends to participate in the North Carolina Local Government Debt Setoff Clearinghouse for the 2026 calendar year. Only ONE form is needed per local government. The participation form covers all departments.
Local Government Name*
Entity Code(ie. C### or M###)*
Type of Participant: If you are a municipality providing utilities, select City/Town/Village, not Water & Sewer (162A Art. 1).

City/Town/VillageCountyWater & Sewer (162A Art. 1)Joint Regional Agency (160A Art. 20)Public Health Authority (130A - Art.2, Part 1B)Metropolitan Sewerage District (162A Art. 5)Sanitary District (130A Art. 2, Part 2)Housing Authority (157)Regional Solid Waste Authority (153A Art. 22)
Coordinator Information

This person will be the entity's primary contact should the Clearinghouse need to reach you.
Coordinator Name:
Coordinator Phone Number
Please enter a valid phone number.
Coordinator Email Address:
example@example.com
Coordinator Email Address (re-enter for verification):
example@example.com
Coordinator Mailing Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Debtor Contact

This person will be the primary contact when a debtor wishes to reach the entity. This may be the same person as the coordinator.
Contact Name:
Contact Phone Number:
Please enter a direct line phone number.
Contact Email address:
example@example.com
Contact Email Address (re-enter for verification):
example@example.com
Additional Information
Hearing Officer and Title/Position:
What name and/or department should debtors be referred to when calling the Interactive Voice Response (IVR)?
What telephone number should debtors be referred to when calling the Interactive Voice Response (IVR)?
Please enter a valid phone number.
Would you like different contacts and phone numbers for different departments/types of debt?

No - just 1 neededYes- please contact Clearinghouse to discussAlready set up - No changes needed at this timeAlready set up - Changes needed; please contact Clearinghouse
What is your current method for transmitting debts (if already participating)? OR What would you like to choose if you are not yet participating?

Client Software: Encrypted Data and Encrypted File Transfer (No Cost)Secure Web Access: Encrypted File Transfers: ASCII ONLY (No Cost)Hardcopy Forms by Secure Fax (No Cost)
Type of Debt(s) currently being submitted (for information only):

Taxes - PropertyTaxes - VehicleUtilitiesEMSHealthAlarmsAnimal ViolationsAssessmentsCivil CitationsCode EnforcementDemolitionsEmployeesEnvironmentalFines (library/other)HousingInspectionsLandfillLoansMaintenance (lawn,trees)NuisanceOrdinance ViolationsParking TicketsPrivilege license (debts prior to 6/30/2015)RecreationReturned ChecksSewer TapSolid WasteStorage RentalStorm WaterTraffic CitationsNone (a new participant)
Other types of debt not listed above:
Name of person completing this form:
Title of person completing this form:
Email address of person completing this form:
example@example.com
Should be Empty:

2026 Annual Participation Form

Coordinator Information

Debtor Contact

Additional Information